rheum

Question 1

wtf is osteoarthritis ? + RF

Answer 1

‘wear and tear’ in synovial joints (not inflam like rheum), result of genetics, overuse and family history
- imbalance between worn down cartilage and chondrocytes repairing it = structural issues in joint. abnormalities can be seen on x-ray

RF: obesity, age, occupation, trauma, female, family history

Question 2

osteoarthritis - key x-ray changes? (mnemonic)

Answer 2

Loss of joint space
Osteophytes (bony lumps growing on bones of spine/joints)
Subchondral sclerosis (increased density of bone along joint line)
Subchondral cysts (fluid-filled holes in bone - geodes)

significant changes could be found in people who do not show symptoms or vice verse

Question 3

presentation of osteoarthritis and commonly affected joints? + 5 general signs in hands

Answer 3

joint pain and stiffness - worsened by activity (this is opposite in rheumatoid)
deformity, instability, reduced function in joint

commonly affected joints: hips, knees, sacro-iliac joints (pelvis), wrists, cervical spine, proximal & distal-interphalangeal joints in hands (PIPs & DIPs), carpometacarpal joint at base of thumb (CMC) - this is a saddle joint: metacarpal bone sat on trapezius used a lot in everyday activity hence wear and tear

hands:
- Heberden’s nodes (DIP joints)
- Bouchard’s nodes (PIP joints)
- squaring at base or thumb at CMC joint
- weak grip
- reduced range of motion

Question 4

diagnosis and management of osteoarthritis ?

Answer 4

can be diagnosed without investigation if patient over 45, has typical activity related pain and has no morning stiffness/sturdiness lasting less than 30 mins

manage:
- patient education about lifestyle changes eg. weight loss, physiotherapy, occupational therapy, orthotics (eg. shoe supports)
- stepwise use of analgesia=
1. oral paracetamol and topical NSAIDs/capsaicin (chilli pepper)
2. oral NSAIDs and PPI to protect stomach eg. omeprazole - better intermittently than continuously
3. opiates eg. codeine, morphine - cautiously as significant side effects, dependence, withdrawal - hence don’t work for chronic pain

intra-articular steroid injections = temporary reduction in inflam and improve symptoms
joint replacement = in severe cases eg. hip and knee

Question 5

wtf is rheumatoid arthritis ?

Answer 5

autoimmune, causes chronic systemic inflammation of synovial lining of joints (synovitis), tendon sheaths and bursa. usually symmetrical and affects multiple joints = symmetrical poly arthritis
inflam of tendons increases risk of tendon rupture
3x more likely in women, usually develops middle age but can present whenever, fam history increases risk

Question 6

rheumatoid arthritis - genetic associations and antibodies ?

Answer 6

genetics:
HLA DR4 - often present in rheumatoid factor (RF) positive patients
HLA DR1 - occasionally present in rheumatoid arthritis patients

RF is autoantibody present in 70% patients which targets Fc portion (portion used to bind to cells of immune system) of IgG antibody = this causes activation of immune system against patients own IgG causing systemic inflam
RF can be any class of immunoglobulin but is usually IgM
(AKA RF is a type of antibody that attacks ANOTHER type of antibody within the body)

Question 7

osteoarthritis vs rheumatoid arthritis:
age of onset, pattern of joint involvement, most common joints affected, joint stiffness, effect of movement, systemic symptoms?

Answer 7

Age of onset: 45+ / 20-40
Pattern of joint involvement: Asymmetrical / Symmetrical
Most common joints affected: DIPJs, Hips, Knees / PIPJs, Wrists and feet , (DIPJs rarely affected)
Joint stiffness: Transient joint stiffness for less than 30 mins / Early morning stiffness for more than 30 mins
Effect of movement: Pain worsens with movement / Pain eases with movement
Systemic symptoms: None / Yes - fatigue and malaise

Question 8

extra-articular manifestations of rheumatoid arthritis?

Answer 8

Subcutaneous nodules
Pulmonary fibrosis with pulmonary nodules - Caplan’s syndrome
Felty’s syndrome - RA + splenomegaly + neutropenia
Anaemia of chronic disease
Episcleritis and scleritis
Carpal tunnel syndrome

Question 9

diagnose rheumatoid arthritis if…? (5 S’s)

Answer 9

Slowly progressive
Symmetrical
Swollen
Stiff
Systemic symptoms (PAIN)

Question 10

What would bloods show in rheumatoid arthritis?

Answer 10

FBC - normochromic normocytic anaemia
ESR/CRP - raised bc RA is inflam
RF - low specificity, raised in 80%
Anti-CCP - high specificity, raised in 30%, worse prognosis

Question 11

rheumatoid arthritis - hand signs (4) and key x-ray changes? (mnemonic)

Answer 11

Boutonniere deformity of thumb
Ulnar deviation
Swan neck deformity
Z shaped deformity of thumb

Loss of joint space
Erosion
Soft tissue swelling
Soft bones

Question 12

manage rheumatoid arthritis?

Answer 12

Non-medical - exercise / lose weight / physio
Pain management
NSAIDs / COX inhibitors (co-prescribed with PPIs)
Corticosteroids - during flare ups to suppress disease activity

Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Gold standard = methotrexate
Taken once a week
Folic acid taken alongside on a different day
Side effects = pulmonary fibrosis + teratogenic (halt pregnancy)

Biological Therapies
Anti-TNF - adalimumab / infliximab / etanercept
Anti-CD20 - rituximab

Question 13

gout crystals vs pseudogout crystals?

Answer 13

gout = monosodium urate crystals
Needle shaped
strong Negative birefringence
yellow

Pseudogout = calcium pyrophosphate dihydrate crystals
rod/rhomboid shaped
weak Positive birefringence
blue

Question 14

wtf is gout? + RF

Answer 14

Inflammatory arthritis associated with chronically high blood uric acid levels (crystal arthropathy)
urate crystals deposited in joint causing it to become hot, swollen, painful
60% occurs at 1st MTPJ of big toe

think of Henry VIII <3
male, obesity, high purine diet (red meat, shellfish, beer), alcohol, diuretics, existing cardio or kidney disease, family history

Question 15

presentation of gout? precipitants of an attack?

Answer 15

Gouty tophi - subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears
DIP joints are most affected in the hands

typically presents with a single acute hot, swollen and painful joint (MTPJ of big toe, wrists, base of thumb/CMCJ)

Chronic polyarticular gout - rare except in pts with renal failure on long term diuretics

Precipitants-
Aggressive intro / sudden cessation of hypouricaemic therapy
Alcohol / shellfish binges 
Sepsis / MI / acute severe illness 
Trauma / surgery / dehydration

Question 16

Diagnose/investigate gout?

Answer 16

Aspirated fluid will show to rule out septic arthritis
shows: no bacterial growth, MSU crystals (needle shaped, strong neg birefringent, yellow)

Joint xray shows: space between joint usually maintained, lytic lesions in bone, punched out erosions which may have sclerotic borders and overhanging edges

Question 17

manage gout?

Answer 17

Acute attacks:
1st line - high dose NSAIDs
2nd line - colchicine - (common side effect = diarrhoea)
3rd line - corticosteroids

Prophylaxis:
Avoid purine rich foods
Reduce alcohol consumption
Lose weight

ALLOPURINOL = XANTHINE OXIDASE INHIBITOR
Less uric acid production = less monosodium crystals
NB - must not start until 1 month after acute attack. Once started can be taken through any following attacks

Question 18

wtf is pseudogout?

Answer 18

crystal arthropathy, deposition of calcium pyrophosphate crystals on joint surface
Shedding of crystals into joint produces acute synovitis resembling acute gout
Typically affects large joints: knee / wrist / hip
(also known as chondrocalcinosis)

Question 19

presentation of pseudogout?

Answer 19

older adult with a hot, swollen, stiff, painful knee. Other joints that are commonly affected are the shoulders, wrists and hips

can be chronic and affect multiple joints
can be asymptomatic (only seen on xray)

Question 20

diagnosis/investigation for pseudogout?

Answer 20

exclude septic arthritis
aspirate synovial fluid will show:
No bacterial growth
Calcium pyrophosphate crystals
Rhomboid shaped crystals
Positive birefringent of polarised light
blue

xray:
Chondrocalcinosis - appears as a thin white line in middle of joint space (calcium deposition) - is diagnostic
other changes similar to osteoarthritis = LOSS

L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts

Question 21

manage pseudogout?

Answer 21

Chronic asymptomatic changes found on xray don’t require action
Symptoms usually resolve on their own over a few weeks
Symptomatic Mx includes NSAIDs /
Colchicine / joint aspiration /
corticosteroids
Joint washout (arthrocentesis) is an option in severe cases

Question 22

wtf is osteoporosis? + RF (mnemonic)

Answer 22

reduction in the density of the bones meaning less strong and more prone to fractures (osteopenia = less severe version)

RF:
MY - personal history of fracture
Steroid use
Hyperthyroidism/hyperparathyroidism
Alcohol/tobacco
Thin (low BMI) - reduced skeletal loading
Testosterone is low
Early menopause
Renal/liver disease
Erosive/inflam bone disease eg. RA
Dietary calcium low/malabsorption
FAMILY - parental history of fracture

oestrogen is a protective factor hence postmenopausal women at higher risk due to lower O levels (unless on HRT)

Question 23

investigate osteoporosis?

Answer 23

X-ray - demonstrates “fragility fractures”

DEXA scan:

• Gold standard
• Measures bone mineral density (BMD) at important fracture sites (hip reading is key)
• Generates Z scores (mean for their age) & T scores - compares BMD against a healthy 30 year old
  hence: most clinically important outcome is the T score at the hip

Calculate FRAX score:

• Predicts the risk of a fragility fracture over the next 10 years
• usually first step

Bone density ranges:
> -1 = normal
-1 -> -2.5 = osteopenia
< -2.5 = osteoporosis

Question 24

manage osteoporosis?

Answer 24

FRAX outcome without a BMD result will suggest one of three outcomes:
Low risk – reassure
Intermediate risk – offer DEXA scan and recalculate the risk with the results
High risk – offer treatment

FRAX outcome with a BMD result will suggest one of two outcomes:
Treat
Lifestyle advice and reassure

Lifestyle Changes:
weight-bearing exercise
healthy weight
good calcium intake
good vitamin D
Avoiding falls
Stop smoking
Reduce alcohol

Med treatment:
bisphosphonates - alendronic acid:
- Decrease osteoclast activity - slows down bone resorption & bone turnover
- Side effects = reflux and oesophageal erosions, Atypical fractures (e.g. atypical femoral fractures), Osteonecrosis of the jaw, Osteonecrosis of the external auditory canal
- Should be taken on an empty stomach, sitting upright for 30 mins before moving or eating
- examples: alendronate, risedronate, zoledronic acid

Denosumab - monoclonal antibody to RANK ligand - inhibits osteoclasts
others: strontium ranelate, raloxifene

HRT - for women that go through the menopause early

Question 25

wtf are seronegative spondyloarthropathies ? + common features (mnemonic)

Answer 25

Group of inflammatory diseases of the spine and sacroiliac joints.
Seronegative = there is NO rheumatoid factor

features:
Sausage digits (dactylitis)
Psoriasis 
Inflammatory back pain 
NSAIDS - good response 
Enthesitis (heel)

Arthritis
Crohn’s / UC / high CRP
HLA-B27
Eye - anterior uveitis / iritis

Question 26

wtf is ankylosing spondylitis?

Answer 26

Chronic inflammatory disorder of spine (vertebral column) and sacroiliac joints
Inflammation causes pain and stiffness - can progress to fusion of joints aka bamboo spine
Inflammation heals with new bone formation - syndesmophytes

(90% of patients with AS have HLA B27 gene
2% of people with gene will get AS)

Question 27

presentation of ankylosing spondylitis

Answer 27

young adult male (late teens/20s)
symp develop gradually across 3 months+
main presenting feature: lower back pain and stiffness, sacroiliac pain (buttock)
worse during rest (sleep - may wake patient up)
improves after 30 mins+ and during day as patient moves more
vertebral fractures are a key complication

Question 28

ankylosing spondylitis associations?

Answer 28

Systemic symptoms eg. weight loss, fever and fatigue
Chest pain (costovertebral and costosternal joints)
Enthesitis - inflam where tendons or ligaments insert in to bone eg. plantar fasciitis and achilles tendonitis
Dactylitis inflam of finger or toe
Anaemia
Anterior uveitis (inflam of middle layer of eye)
Aortitis (inflam of aorta)
Heart block due to fibrosis of heart’s conductive system
Restrictive lung disease due to restricted chest wall movement
Pulmonary fibrosis at upper lobes of lungs (1% of AS patients)
Inflammatory bowel disease

Question 29

investigate ankylosing spondylitis?

Answer 29

schober’s test - mobility of spine (find L5 vertebrae and measure distance 15cm up before and after person bends over, under 20cm indicates AS)

Inflam markers rise
HLA B27 test
xray of spine and sacrum - changes:
- Squaring of the vertebral bodies
- Subchondral sclerosis and erosions
- Syndesmophytes (areas of bone growth where ligaments insert into the bone)
- Ossification of the ligaments, discs and joints
- Fusion of the facet, sacroiliac and costovertebral joints
MRI of spine - may show bone marrow oedema (before any xray changes)

Question 30

manage ankylosing spondylitis?

Answer 30

1st line - exercise and physio
2nd line - NSAIDs
3rd line - anti-TNF eg infliximab / etanercept
4th line - secukinumab - monoclonal antibody against interleukin-17

+ avoid smoking, bisphosphonates to treat osteoporosis, occasional surgery for deformities

Question 31

wtf is psoriatic arthritis? + multiple patterns of disease

Answer 31

inflammatory arthritis associated with psoriasis
Occurs in 10-20% of pts with psoriasis
Multiple patterns of disease:
Symmetrical polyarthritis - similar to RA (hands, wrists, DIP joints)
Asymmetrical oligoarthritis (only affects a few joints/juvenile eg. fingers and toes)
DIPJ arthritis - dactylitis = characteristic
Spondylitic arthritis - similar to ankylosing spondylitis (eg. back stiffness, sacroilitis)
Arthritis mutilans - severe deformity where small bones in hands and feet are destroyed = progressive shortening of digit, skin folding aka ‘telescopic finger’

Question 32

areas to look for hidden psoriasis? + other symptoms

Answer 32

behind/inside ear, scalp, umbilicus, genitals, nails (pitting/onycholysis - separation of the nail from the nail bed)

enthesitis
eye disease (conjunctivitis, anterior uveitis)
aortitis
amyloidosis (abnormal protein, amyloid, builds up in organs and interferes with normal function)

Question 33

investigate and manage psoriatic arthritis?

Answer 33

Investigations:
PEST scoring tool
X-ray - erosive changes
“Pencil-in-cup” deformity

Management:
NSAIDs for pain
DMARDs - eg methotrexate / sulfasalazine
Anti-TNF drugs - eg infliximab

Question 34

wtf is reactive arthritis? + causes

Answer 34

also known as reiter syndrome
synovitis occurs in joints as reaction to recent infective trigger = causes acute monoarthritis affecting single joint in lower limb eg. knee - warm/swollen/painful
unlike septic arthritis, there is no infection in joint

most common infections - gastroenteritis, chlamidya
gonorrhoea causes gonococcal septic arthritis

HLA B27 gene, seronegative spondyloarthropathy